13/07/2015 1 I trattamenti non farmacologici nella prevenzione secondaria dell’infarto Pier Luigi Temporelli Divisione di Cardiologia Riabilitativa Fondazione Salvatore Maugeri, IRCCS, Veruno Difficile non è sapere una cosa, ma sapere far uso di ciò che si sa. Han Fei, Han Fei Tzu, III sec. a.c. Il valore aggiunto di una adeguata prevenzione secondaria
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I trattamenti non farmacologici nella prevenzione ... · Hospitalizations for CV and Respiratory Diseases A Meta-Analysis Tan CE and Glantz SA. Circulation, October 30, 2012 Acute
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13/07/2015
1
I trattamenti non farmacologici nella prevenzione secondaria dell’infarto
Pier Luigi Temporelli
Divisione di Cardiologia Riabilitativa
Fondazione Salvatore Maugeri, IRCCS, Veruno
Difficile non è sapere una cosa,
ma sapere far uso di ciò che si sa.
Han Fei, Han Fei Tzu, III sec. a.c.
Il valore aggiunto di una adeguata prevenzione secondaria
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…“Fumo, ipertensione, diabete, obesità, ridotto consumo di
frutta e vegetali, e mancanza di attività fisica regolare sono
responsabili della maggior parte degli infarti nel mondo intero,
per entrambi i sessi e per tutte le aree abitate”
…“Questi dati suggeriscono che l’approccio alla prevenzione nel
mondo si basa sugli stessi principi ed uno stile di vita corretto è
ovunque in grado di prevenire la maggior parte di casi di infarto
miocardico”
“Our findings suggest that targeted interventions that
reduce blood pressure and smoking, and promote
physical activity and a healthy diet, could substantially
reduce the burden of stroke”
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Risk Reduction
• ASA 20-30%
• Beta Blockers 20-35%
• ACE inhibitors 22-25%
• Statins 25-42%
2-year event rate
6.0%
4.5%
3.0%
2.3%
Potential cumulative impact of four simple secondary-prevention treatments
Yusuf S. Lancet 2002
If all four drugs are used cumulative RRR
is about 75% !!
Riduzione del rischio
• Nessuno ----
• Aspirina 20-30%
• Beta Bloccanti 20-35%
• ACE-inibitori 22-25%
• Statine 25-42%
• n-3 PUFA 20% 1.8%
Eventi a 2 anni
8%
6.0%
4.5%
3.0%
2.3%
Adattata da Yusuf S. Lancet 2002
Impatto cumulativo potenziale dei farmaci in prevenzione secondaria
If all five drugs are used cumulative RRR
is about 85% !!
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Osservatorio ARNO cardiovascolare
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Terapia dopo SCA nel mondo reale
Primo semestre
1. Abolizione del fumo
2. Controllo della dislipidemia
3. Controllo dei valori pressori
4. Regolare attività fisica
5. Controllo del peso corporeo
6. Gestione del Diabete Mellito
7. Terapia anti-aggregante
8. Terapia con ACE-inibitori/Sartani
9. Terapia beta-bloccante
10. Vaccinazione anti-influenzale
11. Cardiologia Riabilitativa
Circulation. November 29,2011
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Key points
Lifestyle changes are vital in the management of stable
angina, including smoking cessation, healthy diet, weight
loss and control of lipid levels
Associated conditions, such as hypertension and diabetes,
should be treated according to relevant guidance
Anti-anginal drugs should be titrated to the optimal licensed
dose to control symptoms
Revascularisation should be considered in selected patients
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Percentage of the Decrease in Deaths from CHD
Attributed to Treatments and Risk-Factor Changes
Ford ES et al. N Engl J Med 2007; 356:2388
The use of revascularization
for chronic angina resulted in
a reduction of approximately
15,690 deaths in 2000, as
compared with deaths in
1980, or approximately
5% of the total and only
1.3% was attributable to PCI.
The Centers for Disease Control
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1. Abolizione del fumo
2. Controllo della dislipidemia
3. Controllo dei valori pressori
4. Regolare attività fisica
5. Controllo del peso corporeo
6. Gestione del Diabete Mellito
7. Terapia anti-aggregante
8. Terapia con ACE-inibitori/Sartani
9. Terapia beta-bloccante
10. Vaccinazione anti-influenzale
11. Cardiologia Riabilitativa
Circulation. November 29,2011
PLoS Medicine 2009; 6:1-23
Smoking and high blood pressure top risk factors for US preventable deaths
The study of 12 modifiable risk factors showed
smoking was responsible for nearly 1/5 US adultdeaths, while high blood pressure accounted for 1/6
Of 2,448,017 US deaths in 2005
467,000 deaths were associated with tobacco smoking
395,000 with high blood pressure
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Produttori di armi da guerra, droghe pesanti
Produttori di
tabacco
Effetti diretti ed indiretti dell’attività di diverse industrie su morbilità e mortalità prematura
nell’uomo
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Decreto Sirchia, gennaio 2003
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Mortality risk reduction associated with smoking cessation in pts with coronary
artery disease
Critchley JA et al. JAMA. 2003;290:86-97
0.1 1.0 10Ceased smoking Continued smoking
RR (95% Cl)Study
Aberg, et al. 1983 0.67 (0.53-0.84)
Herlitz, et al. 1995 0.99 (0.42-2.33)
Johansson, et al. 1985 0.79 (0.46-1.37)
Perkins, et al. 1985 3.87 (0.81-18.37)
Sato, et al. 1992 0.10 (0.00-1.95)
Sparrow, et al. 1978 0.76 (0.37-1.58)
Vlietstra, et al. 1986 0.63 (0.51-0.78)
Voors, et al. 1996 0.54 (0.29-1.01)
Smoking cessation
determines a 25% RR
reduction of MI
recurrence over 2 years
Conclusions.
Our analysis finds smoking to be an independent predictor of
higher 1-year mortality in patients presenting with NSTE-ACS,
and our angiographic study demonstrates CAD in smokers that is
comparable to that in nonsmokers but evident 1 decade earlier.
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Effect of Smoking Relapse on Outcome After Acute Coronary Syndromes
Colivicchi F et al. Am J Cardiol 2011;108:804-8
813 patients out of 1,294 (62.8%) resumed regular smokingThe median interval from discharge to smoking relapse was 19 days (range 9 to 76)
Risk of All-Cause Mortality, Recurrent Myocardial Infarction, and HF Hospitalization Associated With Smoking Status
Following MI With LV Dysfunction
SAVE Investigators, Am J Cardiol 2010; 106:911-16
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Risk of All-Cause Mortality, Recurrent Myocardial Infarction, and HF Hospitalization Associated With Smoking Status
Following MI With LV Dysfunction
SAVE Investigators, Am J Cardiol 2010; 106:911-16
Duration of Smoking Cessation After Myocardial Infarction
6 Months 12 Months 24 Months(adjusted)
Death 0.57 (0.36–0.91) 0.58 (0.33–0.99) 0.53 (0.25–1.08)
Death or recurrent MI 0.68 (0.47–0.99) 0.63 (0.40–0.98) 0.51 (0.28–0.92)
Death or HF 0.65 (0.46–0.92) 0.68 (0.47–0.99) 0.61 (0.39–0.96)
…The approximately 40% lower risk of all-cause mortality associated withsmoking cessation compares favorably to other established therapies forpatients with LV dysfunction after MI, including ACE inhibitors (19%relative risk decrease), Beta blockers (23% relative risk decrease), andaldosterone antagonists (15% relative risk decrease).
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Association Between Smoke-Free Legislation and Hospitalizations for CV and Respiratory Diseases
A Meta-Analysis
Tan CE and Glantz SA. Circulation, October 30, 2012
Acute Respiratory and Cardiovascular Admissions after a Public Smoking Ban in Geneva, Switzerland
Humair J-P et al. PLOS ONE, March 2014
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1. Abolizione del fumo
2. Controllo della dislipidemia
3. Controllo dei valori pressori
4. Regolare attività fisica
5. Controllo del peso corporeo
6. Gestione del Diabete Mellito
7. Terapia anti-aggregante
8. Terapia con ACE-inibitori/Sartani
9. Terapia beta-bloccante
10. Vaccinazione anti-influenzale
11. Cardiologia Riabilitativa
Circulation. November 29,2011
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Physical inactivity in adults worldwide
Hallal PC et al. Lancet 2012;380:247-57
Age Adjusted Mortality Rates in Subjects with CAD categorised by level of fitness
Myers J et al. N Engl J Med. 2002;346:793-801
0
0,5
1
1,5
2
2,5
3
3,5
4
4,5
5
1 2 3 4 5
LEAST FIT
MOST FIT
(3.3-5.2)
(2.4-3.7)
(1.7-2.8)
(1.4-2.2)
1.0
-4.9
ME
T
5.0
–6.4
ME
T
6.5
–8.2
ME
T
8.3
–10.6
ME
T
10.7
ME
T
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Steffen-Batey, Circulation 2000
0
0700 1400 2800
1.0
Survival in days
Su
rviv
al p
rob
ab
ilit
y
0.5
increased
active
decreased
sedentary
2 =46 p<0.001
Survival analysis of mortality by change in level of Physical Activity in Myocardial
Infarction patients
The Corpus Christi Heart Project
Age-adjusted mortality rates/1000 person-yrs in 772 older men (age >65 yrs; follow
up 5 yrs) after MI
Wannamethee S. Circulation 2000
Cardiovascularmortality
All-cause mortality
inactive light moderate vigorous
Physical Activity
20
40
60
Ag
e-a
dju
ste
d m
ort
ali
ty/1
00
0
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InterpretationBoth statin treatment and increased fitness lower all-cause mortality significantlyand independently of other clinical characteristics in dyslipidaemic individuals.Additionally, the combination of statin treatment and fitness lowers mortalitymore than do either alone.
Relative mortality risk by fitness category
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• Reduction of resting and exercise heart rate
• Reduction of resting and exercise blood pressure
• Reduction of myocardial oxygen demand at submaximal
levels of physical activity
• Increase in myocardial contractility
• Favorable changes in fibrinolytic system
• Increased endothelium-dependent vasodilation
• Enhanced parasympathetic tone
• Increases in coronary blood flow, collateral vessels, and
myocardial capillary density
Persone di 3 anni e più che praticano sport, qualche attività fisica e persone non praticanti per sesso - Anni 2001-2009
(per 100 persone di 3 anni e più dello stesso sesso)